The Detection of Medicare Fraud Using Machine Learning Methods with Excluded Provider Labels

With the overall increase in the elderly population comes additional, necessary medical needs and costs. Medicare is a U.S. healthcare program that provides insurance, primarily to individuals 65 years or older, to offload some of the financial burden associated with medical care. Even so, healthcare costs are high and continue to increase. Fraud is a major contributor to these inflating healthcare expenses. Our paper provides a comprehensive study leveraging machine learning methods to detect fraudulent Medicare providers. We use publicly available Medicare data and provider exclusions for fraud labels to build and assess three different learners. In order to lessen the impact of class imbalance, given so few actual fraud labels, we employ random undersampling creating four class distributions. Our results show that the C4.5 decision tree and logistic regression learners have the best fraud detection performance, particularly for the 80:20 class distribution with average AUC scores of 0.883 and 0.882, respectively, and low false negative rates. We successfully demonstrate the efficacy of employing machine learning with random undersampling to detect Medicare fraud.